[Site Name]

Standard Operating Procedure

SOP No.: MTN-032- Version 1.0Page 1of 11

Title:Data Management and Source Document SOP for MTN-032

Original Effective Date: DD MMM YYYY Revision Effective Date: Not Applicable

1.Purpose

To define the Data Management and Source Documentation requirements procedures for MTN-032.

2. Scope

This procedure applies to all MTN-032staff involved in data collection and/or data management for MTN-032.

3. Responsibilities

All site staff members delegated by the Investigator of Record to collect, record, review, and/or transmit MTN-032 study data are responsible for understanding and following this SOP.

The [site to insert appropriate staff job title] is responsible for training study staff to collect and manage study data in accordance with this SOP, and for day-to-day oversight of staff involved in data collection, quality control activities, and data management.

The MTN-032 Investigator of Record (IoR), has ultimate responsibility for the quality of data and for ensuring that all applicable MTN 032 staff members follow this SOP.

4.Procedures

4.1 Participant ID Assignment

For all MTN-032 participants, RTI will assign a range of MTN-032 participant ID numbers (PTIDs). The MTN-032 Interviewers and Study Coordinator should assign one PTID to each participantupon enrollment. PTIDs are assigned in sequential order within the range as participants are enrolled in the study. Staff should ensure that each PTID is assigned only once and may track this by using a Screening and Enrollment Log. Once a participant has received a PTID, she will maintain that same PTID throughout the entire study.

The Participant Status Form (PSF) will capture both the ASPIRE PTID and the MTN-032 PTID (if enrolled) of the participant. The MTN-032 PTID should be used for all subsequent MTN-032 documentation. Staff should enter a “placeholder” PTID of “9999” on the PSF for all individuals who are identified for recruitment or screened, but not enrolled.

MTN-032 PTID boxes are located near the upper left corner of each CRF page. The PTIDs used for this study are four digits long and are formatted as “XXXX”. The range of IDs for [site name] site will be [insert range from Section 3 of SOP].

The PTID/ Name Link log will link PTIDs to participant names. To ensure participant confidentiality, the [insert staff responsible] will be responsible for storing the PTID/ Name Link Log in a secure location, i.e. a locked file cabinet in a locked office, with limited staff access.

5.0 Participant Study Files

5.1Participant File Documentation

Study sites must maintain adequate and accurate participant file records containing all information pertinent to MTN-032 for each study participant. A list of MTN-032 study documents is provided in MTN-032 Study Specific Procedures Manual Section 2 (Table 2-1).

5.2 Participant File Contents

Participant files should contain all of the following elements:

  • Basic participant identifiers
  • Documentation in chart notes that the participant provided written permission to be contacted by ASPIREstaff for future research studies
  • Documentation in chart notes or on Visit Checklist that the participant met the study’s selection (eligibility) criteria
  • Documentation in chart notes or on Visit Checklist that the participant provided written consent to participate in the study prior to the conduct of any study procedures
  • A record of all contacts, and attempted contacts, with the participant
  • A record of all study activities that took place and interview data captured during the conduct of the study
  • In depth interview (IDI) and focus group discussion (FGD)guides, notes recorded on the interview guides and/or separate sheets of paper are to be filed in the participant file
  • Referrals made (including for social harms or unexpected safety events reported)
  • Reason for any deviation required from procedures outlined in the protocol
  • Protocol deviations (where applicable)

6.0 Source Data and Source Documentation

Source data: All information in original records and certified copies of original records necessary for the reconstruction and evaluation of the trial. Source data are contained in source documents (original records or certified copies). [Source: ICH Consolidated Guidance for Good Clinical Practice (ICH-E6)]

Source documents are commonly referred to as the documents – paper based or electronic – upon which the source data are first recorded.

The following will be Source documents for MTN-032

  • Narrative participant file notes
  • Additional notes taken during qualitative data collection
  • Transcriptions and translations of audio files
  • CD of audio recording
  • Case Report Forms (CRFs) and non-CRFs forms
  • Locator form
  • Permission to Contact Form
  • Recruitment List
  • Recruitment Checklist/Script
  • Screening and Enrolment Log
  • Consent Form
  • IC Comprehension Checklist
  • Participant Contact Log
  • CRFs (DEM, PSF, BA, SH, PD)
  • Visit Checklist
  • Discussion Guides (IDI, FGD), Notes and Tools
  • IDI and FGD Debriefing Report

Please Note: The LocatorForm and Permission to ContactForms are ASPIRE forms that will be used for verifying eligibility and recruiting participants for MTN-032. A certified copy of these forms will be made for MTN-032 study files.

7.0Storage

Participant study files will be stored [site to describe above]. The use of participant names to identify study documents will be minimized to the extent possible, and documents bearing participants’ names will be stored apart from documents bearing participants’ PTIDs[KA1]. Logs and other documents linking PTIDs to participant names will be stored securely in a third location.

All files will be stored in locking cabinets in areas with access limited to study staff. During working hours cabinets may remain unlocked if needed to allow staff access to files to conduct participant visits and perform other required data management functions.

No participant identifiers other than the PTID will be recorded on any forms, the CD audio recording, or other documents transmitted to RTI. Written permission will be obtained from participants prior to release of any study-related information outside of the study site that personally identifies the participant.

Any documents transferred or transmitted to a non-study site location — including RTI or a local data management center— must be identified by PTID only. Table 2-1 in Section 2 of the SSP gives a list of documents used for MTN-003D and whether name, PTID, or both are used.

Audio files should be copied onto the password protected hard drive of the Interviewer and onto the hard drive of a computer at the site, and saved onto a CD as source documentation of the interview. The CD should be labeled with the PTID or the FGD ID number, and filed in the participant’s file (if an IDI) or in the FGD file (if an audio recording of the FGD). The audio file should also be uploaded to a secure (encrypted) FTP[1] server for RTI.

7.1Record Retention Requirements

The documents for MTN-032 must be maintained onsite throughout the study’s period of performance, and until further instruction from DAIDS after completion or termination of the study. Study records should not be re-located to an off-site location or destroyed without prior approval from DAIDs. Please refer to Section 2.3 of the MTN-032 SSP manual.

8. Site Data Quality Control

Forms should be reviewed for completeness, legibility, clarity, internal consistency, skip pattern use and accuracy.

  1. During Visit File Reviews (QC Step #1)

Review of participant files/documentation before the end of the visit is critical to ensure participant self reported data are complete and accurate. This includes reviewing theinformed consent, informed consent comprehension checklist, demographic questionnaire, behavioral questionnaire and in-depth interview guide and visit checklist to ensure all required study procedures have been completed. Documents such as these should be carefully reviewed (and updated as needed) before the participant leaves the interview venue. The MTN-032interviewer is responsible for conducting file reviews during the visit.

  1. Post Visit File Reviews (QC Step #2)

Review of participant files/documentation once the visit is completed but prior to transmitting data to RTI is required so that errors and omissions in the CRF data are corrected prior to being entered into the study data base. Once entered into the study data base, data inconsistencies and omissions will result in the creation of Quality Control (QC) notes which require time and effort by study staff and RTI to resolve. By identifying and correcting data errors and omissions prior to transmission, site staff will improve efficiency and reduce time needed to resolve QC notes.

The second review of participant files/documentation will be done by someone other than the person who originally completed the visit documentation and will include all of the visit documentation. The [Study Coordinator or designee] conducts a second CRF review as soon as possible after the visit. This review should happen immediately, and must happen within 2 business days of the visit until instructed otherwise by RTI. CRFs will be reviewed at the site and transmitted to RTI where they will be reviewed and queried. All queries will be resolved through a standardized QC reporting mechanism.

All documents identified as requiring completion or correction will be revised prior to filing (during QC Step #1) and/or transmission to RTI (during QC Step #2).

The table below designates the site staff member(s) responsible for the various tasks associated with site data quality control.

Responsibility / Job Title(s) of Staff Member(s) Responsible
Training site staff on QC #1 process
Training of site staff on QC #2 process
QC #1 Review
QC #2 Review
Periodic evaluation of QC #1 process
Periodic evaluation of QC #2 process

9. CRF data entry procedures

CRFs that are required to be completed at MTN-032 visits are the Participant Status Form (PSF), Behavioral Assessment Form,and the Demographic Form. Additionally, a Social Harms (SH)and/or a Protocol Deviation (PD) is required to be completed when a SH or PD related to MTN-032 study participationis identified.Detailed form completion instructions on how each form should be completed are provided on the back of each form page. Some items on forms are straightforward and do not require specific instructions. Therefore, instructions for all form items are not listed on the back of each form; rather, instructions are provided only for those items needing detailed explanation.

9.1 Data collection

All interviewer- administered CRFs and guides should be administered in the primary language of the participant (as indicated on the ICF). Any deviation from this should be documented in the participant file notes. A visit checklist should guide the order of the procedures for each visit . All participant records must be kept confidential.

9.2 In-depth Interview Procedures

The IDIs will be conducted in a private location to maintain the confidentiality and safety of the participant. This may be the ASPIRE site, or if requested by the participant, a community hall, the participant’s home,or another venue preferred by the participant that is quiet enough for audio-recording. Off-site visit procedures will be described in the Off-site Visit SOP, and review by the MTN-032 Management Team prior to an off-site visit being conducted.

Upon arrival for the IDI visit, the participant will be greeted and offered refreshments (if feasible). The MTN-032 staff will introduce themselves and explain their background and roles during the interview (e.g. interviewer, observer/ note-taker). The MTN-032 staff will then confirm eligibility and conduct the written informed consent procedures. Following the informed consent process and prior to the interview, a staff member will assign a PTID, and update the PSF form. The demographic form (DEM) and behavioral assessment form (BA)will be administered before the IDI. The interview will follow an IDI guide, but will allow for iteration, probing and digression on relevant themes. IDIs will be audio-recorded by the Interviewer and later transcribed and translated by study staff. Following the IDI, the participant will be thanked for her time and reimbursed for her travel and time.

Immediately following each IDI, the facilitator should complete their notes and the PSF. A debriefing report should be completed on the same day as the interview. The debriefing report should be internally QC’dand sent to RTI along with scanned copies of the drug level results tool that contain notes or comments,within one week of the interviewdate for QC. The site should respond to queries (if any) within one week of receipt. Once finalized, RTI will send the final version of the debriefing report to the protocol team.

Refer to Section 7 of the MTN-032SSP for IDI and Qualitative Interview techniques.

9.3 Focus Group Interview Procedures

The FGDs will be conducted in a private location to maintain the confidentiality and safety of the participants. This may be the ASPIRE site or another venue that works for all participants and that is quiet enough for audio-recording. Off-site visit procedures will be described in the Off-site Visit SOP, and review by the MTN-032 Management Team prior to an off-site visit being conducted.

Upon arrival for the FGD, the participants will be greeted and offered refreshments (if feasible). The MTN-032 staff will introduce themselves and explain their background and roles during the interview (e.g. interviewer, observer/ note-taker). The MTN-032 staff will meet with each participant individually to confirm eligibility and conduct the written informed consent procedures. [Site insert your group-IC process if not described in IC SOP]. Following the informed consent process and prior to the FGD, a staff member will assign a PTID, update the PSF form, and complete the demographic form (DEM) and behavioral assessment form (BA). The interview will follow an FGD guide, but will allow for iteration, probing and digression on relevant themes. FGDs will be audio-recorded by the Interviewer and later transcribed and translated by study staff. Following the FGD, the participants will be thanked for their time and reimbursed for their travel and time.

Immediately following each FGD, the facilitator should complete their notes and the PSFs. A debriefing report should be completed on the same day as the discussion. The debriefing report should be internally QC’d and sent to RTI along with scanned copies of the drug level results tool that contain notes or comments, within one week of the interview date for QC. The site should respond to queries (if any) within one week of receipt. Once finalized, RTI will send the final version of the debriefing report to the protocol team.

Refer to Section 7 of the MTN-032 SSP for FGD and Qualitative Interview techniques.

10. Data Management Responsibilities

Study CRFs will be developed by RTI in conjunction with the protocol team and will be manually double-entered in an electronic database. RTI will complete data entry.Quality control reports and queries will be routinely generated and distributed by RTI for verification and resolution.

Within one month of the IDI or FGD session, the interview audio file will be used to simultaneously transcribe and translate the in-depth interviews. Quality checks of the local language transcript and English translation will be done at the site by the interviewerto ensure that they reflect the content of the interview. As directed in SSP Section 7, additional quality checks will occur by site coordinators to ensure accuracy of audio files to transcript. The transcript is then saved and emailed to RTI for review where it will undergo a similar QC process to that of the debriefing reports.

RTI will act as a hub, and manage all data for the study. A convention for file naming will be developed, and all data will be labeled according to this process. Translated transcripts will be transferred to RTI as they are completed. RTI will save all versions of all files on a secure, password protected server.

10.1 Data Flow: Quantitative Data Management

Data for quantitative analysis will be collected manually on CRFs at the site by the interviewers. Data should be checked for accuracy, clarity and completeness at the site. At the beginning of the study, completed CRFS should be transmitted to RTI within two working days of completion. Once a high standard of data quality has been confirmed, CRFs may be batched and efaxed one time per week. (Refer to section 7.6 in SSP manual)

The first five CRFs sent from each site will be double quality control checked by RTI data coordinator and another data analyst. RTI will send one final set of CRFs to sites once all interviews and discussions have been completed at that site.

10.2Data Flow: Qualitative Data Management

MTN 032 interviewers at the site will be responsible for collecting qualitative data. Immediately following the IDI or FGD, the Interviewer (and/or Note Taker, if involved) reviews the guide and expands the notes they have taken during the interview. The audio file is copied onto the password protected hard drive of the Interviewer, and onto the hard drive of the study coordinator’s computer at the site, saved onto a CD and uploaded to a secure (encrypted) FTP server for RTI. (See section 7.7 of SSP manual)